Insurance Medical Examinations Under Florida No-Fault Insurance.
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If you were injured in a motor vehicle accident, your Florida No-Fault Insurance coverage provides for payment of up $10,000 for reasonable and necessary accident related medical care. Under a law pushed by Governor Scott and passed by the legislature, that $10,000 is now limited to $2,500, unless a physician (other than a chiropractor) states you have an injury that requires emergency medical treatment. An emergency room visit is often enough to trigger the insurance company’s obligation to pay up to $10,000. Some people pay extra and buy additional insurance that pays more than the $10,000 limit.
You have chosen your doctor and you are receiving treatment for your accident related injuries. Your doctor is submitting your bills to your motor vehicle insurance company as your doctor is required to do.
What happens when you receive a certified letter from your insurance company stating your insurance company has scheduled you to be examined by a doctor they have selected?
THE REASON: Your insurance company is hoping for an opinion that you do not need any more medical treatment for your injuries so they can stop paying for your treatment. Another possibility is the doctor selected by the insurance company will state your pain and symptoms are related to some pre-existing condition, such as arthritis, and that any further medical treatment would be for that condition and not due to the car accident. With either one of those opinions the insurance company may deny paying your medical bills.
There are a small group of doctors that make their living doing these examinations for insurance companies. The attorneys who represent accident victims know who these doctors are, as we see them providing negative opinions about accident victims on a regular basis.
Some of what we can label “insurance company doctors” even travel from town to town around Florida doing these examinations for insurance companies. I have taken depositions of many of them. They happily travel to places other than their office to do these examinations. I have videotaped their examinations being conducted in curtained cubicles in rehab and massage facilities, in court reporter offices, and in virtual offices rented by the half day. I even videotaped one being conducted in a room in a drug rehab facility that was the only business in an otherwise empty strip mall. These doctors usually schedule multiple examinations, one after the other, at the location they travel to for the insurance company. Not one of these doctors would ever travel for a house call to see one of their own patients.
WHAT IF I REFUSE TO GO?
Are you really required to be examined by a doctor who is a stranger to you that your insurance company has selected?
The answer is you are required to submit to the medical examination ordered by your insurance company. It’s part of your insurance policy. If you refuse to go, your insurance company can stop paying on your claim, including not paying for your medical treatment. What can you do to protect yourself?
What do I do when an insurance company demands that a client of mine be examined by an insurance company selected doctor? To protect my client I attend that examination with my client. I am there to make sure only appropriate questions are asked of my client. Attorneys know there are many instances where the insurance company doctor claims a client said something to the doctor that the client swears the client did not say. I video record what happens so if the insurance company doctor states something occurred that did not occur I have video proof of what really occurred.
THE EXAMINATION AND REPORT
Often these examinations are five minutes of questions and a 5 minute examination. The doctor then sends his report to the insurance company.
For some of these “frequent flyer” insurance company doctors, I have accumulated many copies of their reports from dealing with them in multiple cases. Their reports all read very similar. They start with a template and add a few facts about the individual patient. The concluding opinion is almost always favorable for the insurance company and unfavorable for the accident victim. I have accumulated hundreds of reports from one local doctor who is a favorite of the insurance companies. Over 90% of that doctor’s reports state his opinion that no further treatment would be reasonable, necessary, or related to the accident.
The insurance company gets the report and then sends a letter to the accident victim stating the insurance company will no longer pay for treatment. The goal of the insurance company is for the accident victim to stop getting treatment for their injuries.
These “insurance medical examinations,” which the insurance industry falsely labels “independent medical examinations,” are discussed in many articles on the internet criticizing this tactic that insurance companies use against the people who buy insurance from these companies.
Some companies attempt a cover-up by employing a middle man company to schedule these examinations. The middle man company is paid a fee by the insurance company to be the insurance medical examination scheduler. This allows the insurance company adjusters to claim they did not select the doctor, but the middle man did. The truth is we all know who the doctors are that are used by the insurance companies to do these examinations. It’s the same doctors over and over again whether the examination is scheduled by the insurance company or by the middle man paid by the insurance company.
IT’S ALL ABOUT MONEY
Dr. X does 300 of these examinations a year and is paid $500 per examination. That’s $150,000. If he spends 30 minutes on each one, including his template report, at $500 for each he is making $1,000 per hour. Do you think he wants the insurance company and the middle man to keep scheduling these examinations with him? Do you think he knows that if his report is favorable for the insurance company he will keep getting these examinations scheduled with him?
How about the middle man companies. All they do is schedule the examinations and act as a curtain the insurance company can try to hide behind. They are being paid for every examination they schedule. Some of these companies make hundreds of thousands of dollars a year doing the scheduling. Do you think they are going to schedule examinations with doctors who may give reports unfavorable to the insurance companies? Would they bite the hand that feeds them?
WHAT HAPPENS AFTER AN UNFAVORABLE REPORT FROM THE INSURANCE COMPANY DOCTOR?
What happens first is the insurance company sends a letter telling you they will no longer pay for your medical treatment. Now what? The doctor who has been providing medical treatment for you recommends continued treatment to try and help resolve your injuries. If you stop treatment you might relapse and be worse off. If you have confidence in your treating physician you should consider continuing to follow that doctor’s recommendations. His or her opinions were not the result of a 10 minute visit to an insurance company doctor.
So what happens when your insurance company refuses to pay? Florida law requires, in most instances, that a letter be sent to the insurance company stating if the bills they have refused to pay are not paid within 30 days a lawsuit could be filed for failing to pay the bills. Florida law requires specific language in that letter. The law also requires the letter be sent by certified mail to a person designated by the insurance company to receive those letters. Those letters provide the insurance company with a chance to pay before a lawsuit is filed.
Many times insurance companies pay when receiving the 30 days to pay letter. Why? There are probably two primary reasons.
The first is because they know if a lawsuit is filed they may have difficulty winning it when the facts come out concerning how the insurance comany doctor makes a living just doing these examinations. The other reason is because in these kind of cases if a jury decides in favor of the accident victim, Florida law requires the insurance company to pay the attorney fees of the accident victim. The purpose for this law is to discourage insurance companies from denying claims and forcing lawsuits.
What happens if 30 days goes by and the insurance company still refuses to pay? Some people will decide not to challenge the insurance company and just accept the loss of their insurance benefits. The insurance company is the winner on those claims. Other folks will agree to pursue their claims for their insurance benefits. There are attorneys like me who are experienced in obtaining the insurance benefits through litigation. Other attorneys refer these cases to me.
The first step in the litigation for the insurance company is to re-evaluate their position once the litigation begins. Some companies decide to pay the claims at that point. They flushed out the people who were not willing to pursue their claims in litigation. Now they are faced with defending in litigation their decision to not pay claims. Remember, if the insurance company loses they will also have to pay the accident victim’s attorney’s fees.
The agreement I have with my clients is that I pursue this type of case for a client with the agreement that if we obtain a recovery or benefit that the insurance company had refused to pay, then the insurance company will be required to pay my attorney fees. The insurance company will also be required to pay the court costs I incurred pursuing the lawsuit. That’s the Florida law that we discussed that is designed to discourage insurance companies from not paying valid claims.
I have seen cases where an insurance company has fought like crazy to support its position, paying its attorneys tens of thousands of dollars, and then when the insurance company loses they end up also paying the accident victim’s attorney tens of thousands of dollars as his or her attorney fees. As the amount of the bills being fought over are usually no more than a few thousand dollars, some insurance companies make the business decision and pay the claim when they get the 30-day to pay letter, rather than deciding to roll the dice defending their refusal to pay.
WHY INSURANCE COMPANIES SHOULDN’T PLAY THESE GAMES:
What gets lost in this strategy by the insurance company to minimize what it pays out in claims is the fact that you have paid insurance premiums so that if you are injured in a car accident you can get the medical treatment you need from the doctors you select so that you can recover from your injuries as well as possible. Before an accident happens most people really believe their insurance company is there to help them in their time of need. By the insurance company playing the game of requiring you to be examined by a physician who is a stranger to you, in a strange office, and then refusing to pay for your medical treatment, the result will be you have an unfavorable opinion about the insurance company.
Some insurance companies spend tens of millions of dollars in advertising, sponsoring sporting events, and attempting to brand themselves as a company that will be there when you need them. Then you find out when you need them they pull the rug out from under you, rather than paying your claim.
It’s a bad business tactic by insurance companies. Maybe it happens because the way most insurance companies are set up their adjusters in the claims department are completely separated from the people who sell you the insurance and want to keep you as their customer. The people in claims are focused on the bottom line. The bottom line in claims is paying out as little as you can get away with.